CONGESTIVE HEART FAILURE

A Case Study Presented To The Faculty of Nursing and Health Science Department College of Arts and Sciences Naval State University Naval, Biliran

In Partial Fulfillment of the Related Learning Experience Requirement for the Degree of Bachelor of Science in Nursing

Daryll S. Dacdac

NOVEMBER 2011

TABLE OF CONTENTS Page I. II. III. Introduction Objectives Nursing Assessment 1. Personal History 1.1 Patients Profile 1.2 Family & Individual Information, Social & Health History 1.3 Level of Growth and Development 1.3.1 Normal Development at Particular Age 1.3.2 The ill person at Particular Stage 2. Diagnostic Result 3. Present Profile of Functional Health Pattern 4. Pathophysiology and Rationale 4.1 Anatomy and Physiology 4.2 Schematic Diagram 4.3 Pathophysiology 4.4 Classical and Clinical signs and symptoms IV. Nursing Intervention 1. Care Guide of Patient with Disease Condition 2. Actual Patient Care 2.1 Nursing Care Plan 51 49 35 38 42 44 7 7 7 22 22 27 28 31 4 5

2.2 SOAPIE 2.3 Drug Therapeutic Record 2.4 Health Teaching Plan V. Evaluation and Recommendation VI. Implication of the Case Study VII. Bibliography

65 67 75 79 81 82

INTRODUCTION

Congestive heart failure is defined as the state in which the heart is unable to pump blood at a rate adequate for satisfying the requirements of the tissues with function parameters remaining within normal limits usually accompanied by effort intolerance, fluid retention, and reduced longevity (Denolin, 1983, p. 445). Currently, congestive heart failure or heart failure continues to be a major public health problem worldwide. It is the leading cause of morbidity and mortality in most developed countries. According to the American Heart Association (2001), approximately 5 million patients have heart failure and nearly 550,000 new patients are diagnosed each year. In addition, nearly 300,000 patients die from heart failure yearly.

In the Philippines, cardiovascular diseases are the most common causes of mortality. According to the Department of Health (2005), about 77,060 in a 100, 000 populations have died in the Philippines due to diseases of the heart. The aging of the population and the emerging pandemic of cardiovascular diseases in the developing nations of the world signal a rise in the incidence and prevalence of heart failure globally and magnify the importance of its prevention. The prevention of heart failure is an urgent public health need with national and global implications.

This paper is a case report about Mr. V., a 90 year old male, Filipino and is currently diagnosed with Congestive Heart Failure. Its purpose is to review the pathophysiology, pre-analytical factors, and treatment in a congestive heart failure patient and identify possible recommendations for future nursing care.

This case report is significant to my future nursing care because it helps stress the importance of not only identification and treatment of patients with heart failure but also the importance of promoting a healthy lifestyle and preventive strategies to decrease the prevalence of heart failure in the general population. Also, it explores the need for a thorough case analysis of a client to deliver the best nursing care.

OBJECTIVES General Objectives: After 3 days of student- nurse- patient interaction, the nursing students will be able to gain knowledge, attitude and skills in the care of patient with Congestive Heart Failure. Specific Objectives for the Student- Nurse: After 45 minutes of the discussion, the nursing students will be able to: 1. acquire knowledge about Congestive Heart Failure as to: 1.1 definition of terms; 1.2 risk factors; 1.3 signs and symptoms; 1.4 pathophysiology; 1.5 nursing care plan; 1.6 prognosis; 1.7 interventions? 2. demonstrate proper attitude in handling patient with Congestive Heart Failure and; 3. apply the acquired skills in the care of patients with Congestive Heart Failure.

Specific Objectives for the Patient: After 2 days of student nurse- patient interaction/ SO, the patient will be able to: 1. build trust towards the student- nurse; 2. acquire an overview of the disease as to:

2.1 definition of terms; 2.2 risk factors; 2.3 signs and symptoms; 2.4 complications; 2.5 interventions? 3. verbalize feelings about the situation or condition and; 4. participate in activities done by the student- nurse such as: 4.1 interventions in the care of the condition; 4.2 techniques in managing complications?

III.

NURSING ASSESSMENT

1.1 Patients Profile Patient Name: Age: Sex: Religion: Civil Status: Birthday: Birthplace: Occupation: Date of Admission: Room: Mr. V 90 years old Male Roman Catholic Married November 18, 1920 Calubian, Leyte None August 18, 2010 2:50 pm Male Medical Ward

Chief Complaints: Body Malaise, weakness, difficulty in breathing Impression/ Diagnosis: Congestive Heart Failure Physician: Dr. Borromeo

1.2. Family and Individual Information, Social, and Health History PRESENT MEDICAL HISTORY According to the significant other, two weeks prior to admission, patient was experiencing on and off diarrhea and intermittent abdominal pain after drinking 3- 4 glasses of tuba at their neighborhood. He was not given any medication for diarrhea and for the pain.

The day prior to admission, August 18, 2010, patient claimed that his abdominal pain was getting worst and his stool content was clear water. At around 2:50 pm the patient was delivered at Biliran Provincial Hospital via wheel chair experiencing body malaise, weakness, difficulty in breathing and bipedal edema, patient hence admitted. PAST MEDICAL HISTORY According to the significant other, she does not know if the patient had a complete immunization during his childhood. Wala man siya allergy sa pagkaon, kana la jud ang magkaluya siya ug maglisod pagginhawa pagmukaon siya ug kanang may mga tambok na pagkaon. Karun ra man pud siya nag ing- ana nga may edad na. Di man namo siya mabantayan sa iyang kaonon kay dili man mi tipon ug bahay as verbalized by the significant other. He sometimes drinks tuba and fond of eating oily and fatty foods such as Humda and fries. Most of the time the patient experienced weakness and complaining of back pain at the lumbar area and in the back of the neck. And no alternative remedies were done to treat the symptoms experienced by the patient according to the significant other. According to the SO, June 2010, Mr. V was also admitted in the same institution due to weakness and hypertension. Treatment was not given properly because that day, the significant others decided to discharge the patient due to lack of finance. FAMILY HISTORY According to the SO, patient has a history of hypertension in his paternal side. The father of the patient and one of the patients sons died due to hypertension. The patients mother had a history of arthritis.

Physical Assessment

Physiologic Body Parts Skin: Color: I P P A

Brownness to yellowish Dry and wrinkled Skin turgor back to normal within 4- 5 seconds Presence of bruise in both knees

Texture:

Turgor:

Lesions:

Hair: Color:

Short; grayish

Amount Unevenly and distributed and distribution: alopecia Texture: Parasites: Absence of parasites Dry and oily

Scalp: Symmetry: Symmetrical in shape Texture: Lesions: Nails: Color: No lesions Slightly intact and smooth

Pale, and slightly cloudy

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Shape: Texture: Condition of nail bed: Capillary Refill test:

Convex Smooth Pallor

Back to normal within 2- 3 seconds

Head Size:

Appropriate to body size Rounded Hard

Shape: Consistency:

Face: Symmetry: Symmetrical Facial Features: Patient shows facial grimace when he moves suddenly and when he feels abdominal pain

Neck: Appearance:

Wrinkled skin is noted Able to move in any direction flexion and extension in slow movement Centrally located Not tender

ROM:

Trachea position:

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Thyroid position: Lymph Nodes: Size: Mobility: Consistency: Tenderness: Jugular veins:

Centrally located

Palpable

Not enlarge Not movable Soft Not tender Visible Carotid pulse is palpable but weak, with a pulse rate of 45

Eyes: Position & Appearance:

Appears cloudy to yellowish; sunken; moist, lashes are short

Lacrimal Apparatus:

No discharge upon palpation, no tenderness noted Pupils constricts when light is near and dilates when it is far Patients could not see clearly and takes 30 seconds to 1 minute to recognized faces of his significant

PERRLA:

Visual Acuity:

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other Peripheral Vision: When looking straight ahead, client can recognized objects but could not see clearly in the periphery using penlight

Extraoccular Movement:

Both eyes coordinated move in unison with parallel alignment

Ears: External Ear Size: Shape: Location:

Symmetrical Symmetrical Auricle aligned with outer canthus of eye about 100 from vertical No lesions Not tender

Lesions: Tenderness: Auditory Canal: Cerumen:

Small amount of cerumen noted Yellow to brownness Moist

Color:

Consistency:

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Nose and Sinuses: External Nose: Skin Appearance:

Skin color is uniform No discharge or flaring; hooked with nasal cannula Not tender

Nares:

Tenderness: Internal Nose: Appearance: Septum: Mucosa pink Intact and midline

Sinuses:

Not tender; all sinuses are not inflamed and painless upon palpation Not tender Not inflamed

Tenderness: Transillumina tion: Mouth and Oropharynx Lips: Color: Consistency: Buccal Mucosa: Color: Pallor

Pallor Dry

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Consistency: Gums: Color: Consistency: Teeth: Number:

Moist

Pallor Moist

28 teeth are lost and 3 incisor left at upper teeth and 2 incisor left at lower teeth Presence of dental carries, yellowish in color

Color:

Tongue: Symmetrical: Movement :

Symmetrical Able to move freely Pinkish on the side & with white coating on the center

Color :

Soft Palate: Color: Consistency: Tonsils Position:

Pallor Moist Located at the side of the throat Not tender

Tenderness:

Thorax and Lungs: Anterior and

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Posterior: Color:

Skin color is uniform First rib and clavicle obscured Asymmetrical

Intercostal Spaces:

Chest Symmetry: Respiration:

35 cycles per minute Barrel chest noted

Shape:

Position of Centrally located Sternum: Position of Centrally Trachea: located Tenderness: Vocal Fremitus: Thoracic Expansion: Posterior ICS: Anterior ICS: Not tender Not assessed

Asymmetry less than 3 cm Not assessed Resonance between the 6th ICS at the level of the diaphragm Not assessed

Lateral ICS: Breath Sounds: Crackles are heard specifically at the base of the lower

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lung lobe

Cardiac Assessment Intercostal Space: First rib and clavicle obscured In line with the body

Midsternal Line:

Midclavicular Line:

Center of the midstrenal line R & L anterior line Vertical from the anterior axillary fold

Anterior Axillary Line:

Aortic Area: Pulmonic area: Erbs point Tricuspid area: Mitral Area:

No pulsation No pulsation

No pulsation No pulsation

No pulsation

Blood Pressure: Pulse rate: Brachial Pulse 52 beats per minute

140/ 60 mmHg

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Dorsalis Pedis Breast: Size:

Presence of Edema

Not assessed

Breast even with the chest wall Symmetrical Brownness

Symmetry Color Areola & Nipple: Size

Everted and equal in size Brownness Round Smooth No discharges noted upon palpation Warm to touch Good; back to normal within 1- 2 seconds Not tender Not palpable

Color: Shape: Texture: Discharges:

Temperature: Turgor:

Tenderness: Lymph Nodes Abdomen: Color: Brownness to yellowish in color; glistening skin Abdominal girth is 112 cm

Skin integrity:

Distended; warm to touch

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Umbilicus position:

Centrally located in the umbilical area Not assessed

Contour:

Bowel sounds:

Hypoactive bowel sound noted

Musculoskele tal system: Gait: Not assessed; patient is not allowed to stand 25 % grade of the muscle strength; patient able to move according to his age, but most of the muscles activity test such as hamstring, & sternocleidoma stoid test needs a support from the SO Dry and wrinkled skin is noted; motor function is weak and slow; able to perform extension, flexion of the Skin is warm to touch; less sensation of discriminating the sharp and dull object

Strength:

ROM upper extremities:

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arms in slow manner; patient shows fatigability during the assessment and exert in gasping of air for breathing; able to change his position slowly from lying to side lying position ROM lower extremities: Glistening skin is noted in both legs; bipedal edema is noted; presence of patches at the sole of the feet; bruise noted at both knees; able to adduct and abduct his both legs in slow manner Warm to touch; plantar reflex is difficult to elicit

Cranial nerve I

- patient could hardly identify smell due to the nasal cannula hooked with him; he can identify the odor of his foods being eaten

Cranial nerve II

- patient could not see clearly and it took at least 30 seconds to 1 minute to recognized faces of his significant other

Cranial nerve III

- the extra ocular movement is intact in both eyes when assessed and by using the penlight

Cranial nerve IV Cranial nerve V

- patient could move his eyes up and down - facial sensation of the patient is intact. He was able to feel when touching his face

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Cranial nerve VI Cranial nerve VII Cranial nerve VIII

- patient could move his eyeballs symmetrically when instructed - patient is able to smile, frown when instructed - patient could not hear clearly. When asked questions, it took 2 or 3 times in repeating the question before he could identify what was being asked. He could hear voices when talked near the ears of the patient.

Cranial nerve IX

- patient has positive gag reflex. He could freely move his tongue up and down and side to side.

Cranial nerve X Cranial nerve XI

- patient talked in slow and low tone of voice - patient was able to move his head by moving side to side with limited and slow movement.

Cranial nerve XII

- patient able to protrude his tongue and can move freely from up and down and side to side

Neurologic Assessment Level of consciousness - patient is conscious, and oriented to place where he lived in and he was also aware that he was in the Biliran Provincial Hospital Mood - patient shows uninterested during the first day of interaction. Most of the time, patient sleeps and shows irritable when he was disturb and when feels pain. He shows facial grimace when he experienced abdominal pain. Speech - during the assessment, patient talked slowly and in low voice. He could not identify the question being asked and it took repetition for what was being asked before his response.

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Cognitive abilities

- the patient is conscious. During the assessment, patient sleeps most of the time and talk when he needs something to do with his SO like when he wants to urinate. He can utter few words in low voice when he asked and express facial expression when experienced pain.

Sensory

-during assessment, patient has less sensation of discriminating the sharp and dull object.

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1.3 LEVEL OF GROWTH AND DEVELOPMENT

Normal Growth and Development at Particular Age I. Physical changes

A. Cardiovascular System The heart loses about 1% of its reserve plumbing capacity every year after we turn 30. Changes in blood vessels that serve brain tissue reduce nourishment to the brain, resulting in the malfunction and death of brain cells. By the time we turn 80 and older, cerebral blood flow is 20% less, and renal blood flow is 50% less than when we were age 30. As we age our heart goes through certain structural changes: the walls of the heart thicken and the heart becomes heavier, heart valves stiffen and are more likely to calcify, and the aorta, the major vessel carrying blood out of the heart, becomes larger. B. Musculoskeletal System Bones Aging is accompanied by the loss of bone tissue. The haversian systems in compact bone undergo slow erosion, lacunae are enlarged, canals become widened, and the endosteal cortex converts to spongy bone. The endosteal surface gradually erodes until the rate of loss exceeds the rate of deposition. Bone remodeling cycle takes longer to complete because bone cells slow in the rate of resorption and deposition of bone tissue. The rate of mineralization also slows down. The number of bone cells also decreases because the bone marrow becomes fatty and unable to provide an adequate supply of precursor cells. Because bones become less dense, they become more prone to fractures. Although bone degeneration is inevitable, it is variable if steps are taken before the midtwenties -around this time our bones break down faster than they rebuild. Bone density increases when our bones are stressed, so physical activity is important. Vitamins and good diet also help build up bone mass.

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Joints Cartilage becomes more rigid, fragile, and susceptible to fibrillation. Loss of elasticity and resiliency is attributed to more cross-linking of collagen to elastin, decrease in water content, and decreasing concentrations of glycosaminoglycans. Joints are also more prone to fracture due to the loss of bone mass. Muscles Decrease in the range of motion of the joint is related to the change of ligaments and muscles. As the body ages, muscle bulk and strength declines especially after the age of 70. As much as 30% of skeletal muscles are lost by age 90. Muscle fibers, RNA synthesis and mitochondrial volume loss may all be contributors to muscle decline. Other factors that could contribute to muscle loss of the aged are: change in activity level, reduced nerve supply to muscle, cardiovascular disease, and nutritional deficiencies.

C. Nervous System One of the effects of aging on the nervous system is the loss of neurons. By the age of 30, the brain begins to lose thousands of neurons each day. The cerebral cortex can lose as much as 45% of its cells and the brain can weigh 7% less than in the prime of our lives. Associated with the loss of neurons comes a decreased capacity to send nerve impulses to and from the brain. Because of this the processing of information slows down. In addition the voluntary motor movements slow down, reflex time increases, and conduction velocity decreases. As we age there are some degenerative changes along with some disease's involving the sense organ's that can alter vision, touch, smell, and taste. Loss of hearing is also associated with aging. It is usually the result of changes in important structures of the inner ear. D. Digestive System The changes associated with aging of the digestive system include loss of strength and tone of muscular tissue and supporting muscular tissue, decreased secretory mechanisms, decreased motility of the digestive organs, along with changes in neurosensory feedback regarding enzyme and hormone release, and diminished response to internal sensations and pain. In the upper GI tract common changes include periodontal

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disease, difficulty in swallowing, reduced sensitivity to mouth irritations and sores, loss of taste, gastritis, and peptic ulcer disease. Changes that may appear in the small intestine include appendicitis, duodenal ulcers, malabsoration, and maldigestion. E. Urinary System As we get older kidney function diminishes. By the age of 70 and older, the filtering mechanism is only about half as effective as it was at age 40. Because water balance is altered and the sensation of thirst diminishes with age, older people are more susceptible to dehydration. This causes more urinary tract infections in the elderly. Other problems may include nocturia (excessive urination at night), increased frequency of urination, polyuria (excessive urine production), dysuria (painful urination), incontinence, and hematuria (blood in the urine F. Respiratory Systems With the advancing of age, the airways and tissue of the respiratory tract become less elastic and more rigid. The walls of the alveoli break down, so there is less total respiratory surface available for gas exchange. This decreases the lung capacity by as much as 30% by the age of 70 or older. G. Vision Changes in vision begin at an early age. The cornea becomes thicker and less curved. The anterior chamber decreases in size and volume. The lens becomes thicker and more opaque, and also increases rigidity and loses elasticity. The ciliary muscles atrophy and the pupil constricts. There is also a reduction of rods and nerve cells of the retina. H. Hearing Approximately one third of people over the age of 65 have hearing loss. The ability to distinguish between high and low frequency diminishes with age. Loss of hearing for sounds of high-frequency (presbycusis) is the most common, although the ability to distinguish sound localization also decreases. It is believed that the hearing loss isn't so much an age change as it is due to the accumulation of noise damage.

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I. Taste and Smell Sensitivity to odors and taste decline with age. The sense of smell begins to degenerate with the loss of olfactory sensory neurons and loss of cells from the olfactory bulb. The decline in taste sensation is more gradual than that of smell. The elderly have trouble differentiating between flavors. The number of fungiform papillae of the tongue decline by 50% by the age of 50. Taste could also be affected by the loss of salivary gland secretions, notably amylase. This loss of taste and smell can have a significant effect on an elder's health. With the reduced ability to taste and smell, it is difficult to adjust food intake as they can no longer rely on their taste receptors to tell them if something is too salty, or too sweet. This can also cause the problem in that they might not be able to detect if something is spoiled, making them at a higher risk for food poisoning. J. Cellular Aging As people age, oxygen intake decreases as well as the basal metabolic rate. The decrease in the metabolic rate, delayed shivering response, sedentary lifestyle, decreased vasoconstrictor response, diminished sweating, and poor nutrition are reasons why the elderly cannot maintain body temperature. There is also a decrease in total body water (TBW). K. Organism Aging Aging is generally characterized by the declining ability to respond to stress, increasing homeostatic imbalance and increased risk of disease. Because of this, death is the ultimate consequence of aging. Differences in maximum life span between species correspond to different "rates of aging". For example, inherited differences in the rate of aging make a mouse elderly at 3 years and a human elderly at 90 years. These genetic differences affect a variety of physiological processes, probably including the efficiency of DNA repair, antioxidant enzymes, and rates of free radical production.

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II. Cognitive development According to Piagets phases of cognitive development, it ends with the formal operations phase. In older adults, changes in cognitive abilities are more often differences in speed than ability. Overall the older adult maintains intelligence, problem solving, judgment, creativity, and other well- practiced cognitive skills. Intellectual loss generally reflects a disease process such as atherosclerosis, which causes the blood vessels to narrow and diminishes perfusion of nutrients to the brain. Older adults do not experiencing cognitive impairments. III. Moral development According to Kohlberg, moral development is completed in the early adult years. Most old people stay at Kohlbergs conventional level of moral development and some are at the preconventional level. An older person at the preconventional level obeys rules to avoid pain and the displeasure of others. At stage 1, a person defines good and bad in relation to self, whereas older people at stage 2 may act to meet anothers need as well as their own. Older adults at the conventional level follow societys rules of conduct in response to the expectation of others. IV. Spiritual development Older adults can contemplate new religious and philosophical views and try to understand ideas missed previously or interpreted differently. Involvement in religion often helps the older adult to resolve issues related to the meaning of life, to adversity, or to good fortune. The old- old person who cannot attend formal services often continues religious participation in a more private manner. Many older adults watch television evangelists and some, being vulnerable to fund- raising ventures, sent these organizations money that they can ill afford to spare.

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The Illness Person at the Particular Stage Declining physical and sensory- perceptual abilities limit the ability of old- old stage adult to respond to environmental hazards and stressors. In old- old age group, ill client may experience behavioral and emotional changes, changes in self- concept and body image, and lifestyle changes. Behavioral and emotional changes associated with short- term illness are generally mild and short lived. The individual may become irritable and lack the energy or desire to interact in the usual fashion with family members with friends. The clients self- esteem and self- concept may also be affected to a certain illness which can also change the clients body image or physical appearance. Many factors can play a part in low self- esteem and a disturbance in self- concept: loss of body parts and function, pain, disfigurement, dependence on others, unemployment, financial problems, inability to participate in social functions, strained relationship with others, and spiritual distress.

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2. DIAGNOSTIC RESULTS Diagnostic Test Blood Chemistry *Sodium *Potassium *FBS *Creatinine 135- 155 mmol/L 3.5- 5.5 mmol/L 3.33 6.10 mmol/L
M:61.8-123.7 mmol/L

Normal Values

Patients Result

Significance

153.5mmol/L 3.8mmol/L a. mmo l/L 180.3 mmol/L

Normal Normal Normal Increase; indicates systemic disease such as hypertension and renal insufficiency

F: 53- 97.2 mmol/L

(Ref: Joyce Black And J. Hawks, Medical- Surgical Nursing, 8th Edition, Pp. 1383 & 20002001) Hematology *Haemoglobin M:134- 180 g/L F:120- 160 g/L 90 g/L Decrease; indicates hemodilution (fluid overload) M: 44- 54 vol. % F: 38- 45 vol. % 5- 10 x 10/ L 12 55-75% 8.7 x 10 /L 12 75.1% 28.4 % Decrease; indicates hemodilution (fluid overload) *WBC *Neutrophil Normal Slightly increase; indicates acute infection

*Haematocrit

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*Lymphocytes

20- 35% 18. 9%

Decrease; indicates exhausted immune system

*Monocytes

2-6% 6.0%

Normal (Ref: Barbara Kozier, Glenora Erb, At Al, Fundamentals Of Nursing, 7th Edition 2004, Pp. 759t) Black and Hawks; Medical- Surgical Nursing; 8th edition, volume 2, pp. 2001

Urinalysis Macro: *Blood *pH *Specific Gravity Micro: *WBC *RBC Negative Negative 0-1 HPF 0-1 HPF (Ref: www. Naturalhealthtechni ques.com Negative 6-8 1.010- 1.025 Negative 6.0 1.015 Normal Normal Normal Normal Normal

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The chest x-ray done on August 19, 2010 was indicated to view the structures of the chest (bones, heart, lungs) for any abnormalities. Also, the client was suspected of Pulmonary Tuberculosis and Community-Acquired Pneumonia so this chest x-ray is to rule out or confirm said conditions. It is also indicated for a definite diagnosis of cardiomegaly or congestive heart failure in the patient and is done to reassess the patient's heart condition (size, shape, structure). The chest x-ray revealed that there are high suspicions of granulomatous pulmonary nodule in the right upper lung zone. Inflammatory process is also considered in the left upper lung zone. It also suggested undergoing another chest x-ray in an apicolordotic view for further evaluation of athermanous and tortuous aorta.

Ultrasound was performed on August 22, 2010 to view the peritoneal cavity and identify possible problems that may be the cause of hematuria. A part that has been examined is the flat plate of the abdomen. Finding shows that the marginal sclerosis and osteophytes are already widen on the bodies of the lumbar vertebrae with preserved disc spaces. In addition, ultrasound revealed non- obstructive bowel pattern. There is also a degenerative change of the lumbar spine.

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3.

PRESENT PROFILE OF FUNCTIONAL HEALTH PATTERN

GORDONS HEALTH PATTERN I. Health Perception Health Management Pattern

Prior to hospitalization, the patient experienced diarrhea and weakness after he drinks tuba. He had his unusual pattern of eating due to abdominal pain experienced by the patient. During hospitalization, the SO was aware that the patient had hypertension. Their goals were to recover their father and were able to discharge as soon as possible. During assessment, patient was weak and could not mobilize his body properly. He could not open his eyes and could utter only few words in low voice. Upon admission, the patient received 3 Litters per minutes of Oxygen immediately and 1 tablet of 100 mg of Spironolactone twice a day. II. Nutritional Metabolic Pattern

Prior to hospitalization, patient was fond of eating foods that are rich in oil and fat such as Humba and drinking tuba at least 1 litter. According to the SO, he does not have any allergy in foods and in medicine. She claimed that his father could not eat properly because of the incomplete teeth and can only eat soft foods like lugaw and cereals. He drinks water at least 5 to 6 glasses of water only per day. Upon hospitalization, patient could not eat properly because he could not chew the food properly and he could not eat in sitting position unless assisted by his significant other due to the developing ascites and abdominal pain. The SO verbalized, Pukawon ra na siya namo ug mukaon na siya. The patient has low sodium, low- fat diet as prescribed by the physician. The SO also added that his father drinks water in small amount and could not drink at least 2 glasses in a day and or sometimes just a sip of it.

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III.

Elimination Pattern

Two weeks prior to hospitalization, patient was experiencing watery stool in small amount. Nakalibang siya kadtong ning labay nga duha ka-adlaw, dulaw nya basa ug gamay ra kayo, as verbalized by the SO. He can urinate two times a day without any pain upon urination. Eight days prior to admission, SO added that his fathers feet were swelling and getting bigger after experiencing abdominal pain. Upon hospitalization, Gikan atong na- admit siya nya nahatagan na ug tambal, magihi- ihi siya. Manga unom ka-beses o sobra pa sa usa ka-adlaw. Pero wala pa siya nalibang sukad adtong na-admit siya as verbalized by the SO. During the assessment, patient urinates in a bed pan and his urine was yellowish to clear in colour. His feet were still swelling and his abdomen develops ascites and both of it were yellowish in colour. IV. Activity Exercise Pattern

According to the SO, patient can walk slowly when assisted with grandson. He just stayed in their house most of the time and watching TV every afternoon. During hospitalization, patient was lying in his bed. He could not sit down by himself due to the ascites and abdominal pain. He sleeps most of the time and awakes when the time he ate and was assisted by his SO. He needs assistance in urinating using the bed pan. V. Sleep- Rest Pattern

According to the SO, prior to admission, patient sleeps around 8 P.M. and awakes at around 7 A.M. or sometimes 8 in the morning. He sleeps for about 1 to 2 hours every afternoon whenever he does not watch television. Upon hospitalization, the SO states that, Mag sige ra siya ug katug, makamatngon gad siya kung among pukawon, naay oras nga mag sige ra siya ug katug jud nya amo na lang pukawon pagpakaon.

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VI.

Cognitive- Perceptual Pattern

Prior to admission, SO stated that, the patient has defect in his sight and hearing. But patient was not able to use any aid or any devices in his sight and hearing problem. During hospitalization, the patient is conscious and oriented to place. During the assessment, patient sleeps most of the time and talk when he needs something to do with his SO like when he wants to urinate. He can utter few words in low voice when he asked and express facial expression when experienced pain. VII. Self- Perceptual Pattern

According to the SO, prior to admission, the patient experienced poor appetite. He showed unwillingness when his wife asked about his condition. The SO also added that they were concerned about his fathers condition especially to his abdomen because of the ascites and in financial aspects too. During the hospitalization, the patient becomes thin and sometimes unresponsive. The SO stated that, Bahala na lang kung kulang amo kwarta basta ang amo lang ang pagpakaayo sa among amahan nga mabalik lang iyang panglawas ni-ari. VIII. Role Relationship pattern The family of Mr. V is said to be extended and patriarchal. He lives with his wife who is 86 years old. His two grandsons live also with them who helped in their daily needs. According to his wife, they depend to their 5 daughters who supported them financially. Their 5 daughters were separated from them and all of them were married. During the stay of the patient in the hospital, their children always contribute to the medical expenses of the client. Currently, they feel worried about their father's condition and contribute to any way they can to alleviate his condition. The usual problem of the family involves the drinking habit of the patient and financial problems. They usually resolve it by conversations with the family.

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IX.

Sexuality- Sexual Function

Mr. V is a 90 years old male, married with 5 children. According to his wife, she and his husband has not engaged in sexual intercourse in recent years. She claims that this is because they are already old. She also added that, her daughter noticed that there is a whitish secretion on the penis of his father when she cleansed her fathers genitalia.

X.

Coping- Stress Management

According to the SO, patient stays only on their house. When his father experienced pain, they just let their father rest and no medications were given to alleviate to ease the pain. And during the hospitalization, she claimed that his father always lying on bed and always sleeping. In addition, they helped his father to cope with his condition by changing his lifestyle for the better, avoiding foods that are contraindicated to his fathers condition and taking rest periods. However, the patient does feel bothered about the expenses incurred by his children for his medical condition.

XI.

Value- Belief System

Mr. V and his family was Roman Catholic but seldom visit a church. According to the SO, it was long time ago when his father visit the church. They believe in Kwak doctors but they were not able to consult in a Kwak doctor once. During the hospitalization, they do not wish to see a priest at present. According to the SO, their family accepts of his fathers condition. They do not fear death but they wishes that their father will live longer for their family.

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4. PATHOPHYSIOLOGY AND RATIONALE 4.1 Anatomy and Physiology To understand what occurs in heart failure, it is useful to be familiar with the anatomy of the heart and how it works. The heart is composed of two independent pumping systems, one on the right side, and the other on the left. Each has two chambers, an atrium and a ventricle. The ventricles are the major pumps in the heart.

The external structures of the heart include the ventricles, atria, arteries, and veins. Arteries carry blood away from the heart while veins carry blood into the heart. The vessels colored blue indicate the transport of blood with relatively low content of oxygen and high content of carbon dioxide. The vessels colored red indicate the transport of blood with relatively high content of oxygen and low content of carbon dioxide.

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The Right Side of the Heart

The right system receives blood from the veins of the whole body. This is "used" blood, which is poor in oxygen and rich in carbon dioxide. y y The right atrium is the first chamber that receives blood. The chamber expands as its muscles relax to fill with blood that has returned from the body. y y The blood enters a second muscular chamber called the right ventricle. The right ventricle is one of the heart's two major pumps. Its function is to pump the blood into the lungs. y The lungs restore oxygen to the blood and exchange it with carbon dioxide, which is exhaled.

The Left Side of the Heart

The left system receives blood from the lungs. This blood is now oxygen rich. y The oxygen-rich blood returns through veins coming from the lungs (pulmonary veins) to the heart. y y It is received from the lungs in the left atrium, the first chamber on the left side. Here, it moves to the left ventricle, a powerful muscular chamber that pumps the blood back out to the body. y The left ventricle is the strongest of the heart's pumps. Its thicker muscles need to perform contractions powerful enough to force the blood to all parts of the body. y This strong contraction produces systolic blood pressure (the first and higher number in blood pressure measurement). The lower number (diastolic blood pressure) is measured when the left ventricle relaxes to refill with blood between beats. y Blood leaves the heart through the ascending aorta, the major artery that feeds blood to the entire body.

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The Valves

Valves are muscular flaps that open and close so blood will flow in the right direction. There are four valves in the heart: y The tricuspid regulates blood flow between the right atrium and the right ventricle. y The pulmonary valve opens to allow blood to flow from the right ventricle to the lungs. y The mitral valve regulates blood flow between the left atrium and the left ventricle. y The aortic valve allows blood to flow from the left ventricle to the ascending aorta.

The Heart's Electrical System The heartbeats are triggered and regulated by the conducting system, a network of specialized muscle cells that form an independent electrical system in the heart muscles. These cells are connected by channels that pass chemically caused electrical impulses.

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4.2 Schematic Diagram of the Disease Process

Congestive Heart Failure

Non- modifiable Risk Factor *Family History of Hypertension (Father) * Age (older than 65) *Gender (Men) Race

Modifiable Risk Factor *Lack of access to medical service due to low socio- economic strata (unemployed) *Poor Nutrition (inadequate food intake) *High Sodium and Cholesterol in diet Alcohol Consumption Sedentary Lifestyle

Decreased elasticity of blood vessels and formation of plaques on blood vessels

Narrowing of the blood vessels

Necrosis and Scarring of the vascular endothelium

Impediment of blood flow to the body

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Increased workload of the heart

Dilation of ventricles

Increased in preload

Increased in stretching of myocardial muscle

Excessive stretching of myocardial muscle

Ineffective cardiac muscle contraction and increase Oxygen demand of cardiac muscle cells

Decreased contraction of cardiac muscle

Decreased cardiac output and systemic perfusion

Activation of neurohormonal pathways in order to increase circulating blood vessels

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Continued neurohormonal stimulation

Cardiac remodeling

Decreased blood filling

Increased stroke volume and decreased cardiac output

Inadequate perfusion

Increased wall tension

*Pallor

Decreased blood flow to the kidney

Decreased perfusion in the coronary arteries

Increased pulmonary pressure

Separation of mitral valve leaflets

Increase pulmonary pressure Kidney produce hormone Salt & water retention *Edema Deprivation of cardiac muscles cells of nutrients needed for survival *Fatigue & weakness

Impaired left ventricular relaxation

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Normal balance between Oxygen supply & demand is disrupted

Increased diastolic pressure exceeding hydrostatic & osmotic pressure in pulmonary capillaries

Ischemia

Increased capillary pressure in the lungs

Conversion of aerobic metabolism to anaerobic metabolism

Fluid shifts from the circulating blood into the interstitial, bronchioles, bronchi and alveoli

Causes reduced contractility

Decreased adenosine

Decreased lung expansion

Pulmonary congestion

Decreased the hearts ability

Increased lactic acid production

*Dyspnea

Fluid trapped in pulmonary trees

Irritation of myocardial cells

*Bilateral Crackles

Chest Pain

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4.3 Discussion of the Disease Process Regardless of the precipitating event, the common mechanism of heart failure is quite complex. Compensatory mechanisms exist on every level all the way to organ interactions. When this compensatory mechanisms and adaptation are overwhelmed, heart failure happens (MacIntyre, et. al, 2000). In this section, it focuses on the pathophysiological mechanisms that led to the presentation of signs and symptoms of the client, and its current treatment and identified nursing diagnosis. Figure above shows the pathophysiology of the disease with the risk factors, presenting signs and symptoms.

Porth (2007) discloses that due to the infiltration of group A beta-hemolytic streptococci, antibodies in the body react to destroy the bacteria simultaneously causing acute inflammation to the heart. During the acute inflammatory stage of the disease, the valvular structures become swollen. Small vegetative lesions develop on the valve leaflets. It then proceeds to the development of fibrous scar tissue which tends to contract and cause deformity of the valve leaflets and shortening of the chordae tendinae.

During much of the systole, the mitral valve is subjected to high pressure generated by the left ventricle as it pumps blood to the systemic circulation. Increased preload occurs because the incomplete closure of the mitral valve permits the regurgitation of blood from the left ventricle into the left atrium (Porth, 2007). In addition, incomplete closure of the aortic valve also results in increased preload as the left ventricle is forced to pump the entire diastolic volume received from the left atrium and the regurgitant volume from the aorta. Increased afterload occurs as there is increased pressure for the heart to generate the movement of the increased volume from the left ventricle into the aorta. The increased volume work causes increased pressure for the left ventricle to pump more blood. This eventually leads to left ventricular hypertrophy (Porth, 2007).

As the workload increases, the walls of the chamber grow thicker, losing their elasticity and eventually may lead to myocardial dysfunction and eventually myocardial

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failure (Woods, et. al., 2010). This results to the failure of the heart to pump with as much force as a healthy heart. Systolic dysfunction or failure is evident leading to altered systemic perfusion and decrease in end-systolic volume. A decrease in end-systolic volume causes a decrease in cardiac output which also contributes to the decrease perfusion of tissues in the body. Alterations in systemic perfusion result in neuroendocrine activation. This includes increase in sympathetic activity, activation of the renin-angiotensin-aldosterone pathway and eventual decrease in oxygen supply in tissues.

Woods (2010) explains that increased activity of the sympathetic nervous system or the renin-angiotensin-aldosterone system [RAAS] results in vasoconstriction of the small arterioles. In the RAAS, vasoconstriction leads to increased peripheral vascular resistance. The RAAS also increases aldosterone production thus enabling the retention of sodium and water. This leads to an increase in plasma volume. Increased plasma volume and decreased end systolic volume leads to increased venous pressure to the lungs. This increase in hydrostatic pressure causes an increase in the rate of filtration of fluid out of the capillaries and into the interstitial compartment (Woods, 2010). As a result, the lungs fill with fluid, a condition called, pulmonary edema and eventually pulmonary congestion.

On the other hand, increased activity of the systemic nervous system is caused by the release of epinephrine and norepinephrine (Porth, 2007). The purpose of this initial response is to increase heart rate and contractility and support the failing myocardium. Sympathetic stimulation causes peripheral vasoconstriction. Peripheral vasoconstriction may cause capillary endothelial damage.

Decreased oxygen supply in tissues is detrimental because if oxygen delivery to cells is insufficient for the demand, prolonged compensatory mechanisms can lead to cell death (Hobler & Karey, 1973). Decreased perfusion to the tissues and eventual decrease in oxygen supply causes increased myocardial workload as it attempts to compensate for the reduction (Smeltzer & Bare, 2010). Eventually, compensatory mechanisms fail and

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even the myocardium experiences a decrease in oxygen supply (Porth, 2007). This decreases oxygen supply to the brain and induces decreased oxygen supply in the blood. When this happens, the heart muscle must use alternative, less efficient forms of fuel so that it can perform its function of pumping blood to the body or commonly called anaerobic metabolism (Porth, 2007). The by-product of using this less efficient fuel is a compound called lactic acid that builds up in the muscle and causes chest pain.

4.4 Clinical and Classical Symptoms Classical symptoms Abdominal distention Clinical symptoms Manifested Rationale - Fluid overload throughout the cardiovascular system causes fluid to build up in the abdomen. Source: http://www.medicine. com/congestive_heart failure/article.html

Abdominal pain

Manifested

- Abdominal pain, nausea, decreased appetite occurs due to the accumulation of fluid in the liver and intestines. Source: http://www.medicine.com /congestive_heartfailure/a rticle.html

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Crackles in the lungs

Manifested

- Adventitious breath sounds may be heard in various areas of the lungs. Usually, bibasilar crackles that do not clear with coughing are detected in the early phase of left ventricular failure. Crackles, heard initially in the lung bases, and when severe, throughout the lung fields suggest the development of pulmonary edema (fluid in the alveoli). Source: http://www.medicine.com /congestive_heartfailure/a rticle.html

Fatigue and weakness

Manifested

- Less blood to your major organs and muscles makes you feel tired and weak. Inadequate cardiac output leads to hypoxic tissues and slowed removal of metabolic

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wastes, which in turn cause the client to tire easily. Source: - Black, Joyce M. et.al; Medical Surgical Nursing Clinical Management for Positive Outcomes; 8th edition; volume 2; p. 1437

Jugular vein distention

Manifested

- The right side of the heart cannot eject blood and cannot accommodate all the blood that normally returns to it from the venous circulation. The increase in venous pressure leads to jugular vein distention. Source: http://www.medicine.co m/congestive_heartfailu re/article.html

Nocturia

Not manifested

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Shortness of breath (dyspnea)

Manifested

- With failure of the left ventricular myocardium (heart

Sleep apnea

Manifested

muscle), the blood tends to backup in the lungs with elevated pressure causing shortness of breath (dyspnea), orthopnea (having to sit to breathe) and paroxysmal nocturnal dyspnea

Source: http://www.medicine.co m/congestive_heartfailu re/article.html Manifested

Sudden weight gain

- As the body becomes overloaded with fluid from congestive heart failure, patient may experience a sudden weight gain.

Source: http://www.medicine.com /congestive_heartfailure/a rticle.html

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Swelling (edema) in legs, ankles

Manifested

- Edema from congestive heart failure is a result of the heart inability to pump blood and fluids back through the cardiovascular system. As the fluid "waits" to be pumped back through the heart, it builds up in the leg and begins to "leak" out of the permeable structure of the veins. Source: http://www.medicine.com /congestive_heartfailure/a rticle.html

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IV.

NURSING INTERVENTION

4.1 Care Guide of Patient with Disease Condition The following are the goals of nursing management for the client with Heart Failure: Guidelines Adhere to dietary restrictions Interventions  Sodium in the diet should be limited to 4 g per day initially until fluid and weight gain are controlled.  Fluid restriction may also be needed. Follow as what the physician advice.  Clients or family members should be taught how to measure BP daily, especially if the client has diastolic heart failure.  During the severe stages of heart failure, the client should remain on bed rest with the head of the bed elevated and elastic stockings or wraps worn to mobilize edema. Once the client can breathe comfortably during activity, activity should be increased gradually to help increase strength.

Monitor blood pressure

Modify activity

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Adhere to medications

 The multiple medications will require some type of system to prevent missed or duplicate doses. Instruct to take the diuretics in the morning to that trip to the bathroom happen during the day. Taking diuretics in the evening or at night often results in interrupted sleep because the urge to empty the bladder continues for hours. Reference: Black and Hawks, Medical and Surgical Nursing 8th edition, pp1446- 1447